WI0400247_GEO THERMAL_20120418

Permit Number
Program Category
Ground Water
Permit Type
Wl0!4,00247 /
Injection Water Only GSHP Well System (5QW}
Primary Reviewer
eric.g.smith
Coastal SW Rule
Permitted Flow
Facility ·
Facility Name
David & Kathryn Adams SFR
Location Address
4700 Duffer Ln
Pfafftown
Owner
Owner Name
David
Dates/Events
NC 27040
Adams
Scheduled
Orig Issue
04/18/12
App Received Draft Initiated Issuance
04/09/12
Regulated Activities
Heat Pump Injection
Outfall NULL
Central Files: APS_ SWP_· _
04/18/12
Permit Tra_~~ing Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Perm it Contact.Affiliation
David J. Brown
1908 Hamptonville Rd
Hamptonville NC
Major/Minor
Minor
Region
Winston-Salem
County
Forsyth
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
David· Adams
4 700 Duffer Ln
Pfafftown
Public Notice Issue
04/18/12
NC
Effective
04/18/12
27020
27040
Expiration
Waterbody Name Stream Index Number Current Class Subbasin
Beverly Eaves Perdue
Governor
David Adams
Kathryn Adams
4 700 Duffer Lane
Pfafftown, N.C. 27040
AVA
.N CDENR ,
North Carolin·a Department of Environment and Natural Resources
Division of Water Quality
Charles Wakild, P .E-.
Director
April 19, 2012
Subject: Acknowledgement of Intent to Construct Type 5QW Injection Well ·System
Permit No. WI040024 7
-Injection we]lsystem address
Dear David & Kathryn:
Dee Freeman
Secretary
On April 9, 2012, the Aquifer Protection Section (APS) received notification of your intent to construct a closed-loop water-only
geothermal injection well system for · the operation of a ground-source heat pump located · at the address referenced above. 'An
individual permit is not required for the construction and operation of this type of geothermal injection well system as long as the
following conditions are met: .
1. The injection well system contains only potable water,
2. The ·injection well system is constructed in accordance with well construction standards specified in North
Carolina Administrative Code Title 15A Section 2C Subchapter .0213, and
3. The required notification form and associated maps have been completely and accurately submitted.
Failure to comply with all of these conditions constitutes a violation of the. North Carolina Well Construction Act and North Carolina
Administrative Code Title 15A Se~tion 2C Subchapter .0211(u)(2). Additionally, you should contact the Forsyth County Health
Department as they may have additional requirements for this type of system. Noncompliance with applicable state, county, or
municipal rules and regulations may result in the assessment of civil penalties.
Please contact Mike Rogers at [phone] ()r [e-mail] ifyouhave any questions.
cc: Winston-Salem Regional Office -APS
APS Central Files -Permit No. Wl0400247
Forsyth County Health Dept. ·
Yadkin Well Co. Inc. (David J. Brown)
Logan heating & Air, Inc. (Mark Hollingsworth)
AQUIFER PROTECTION SECTION
1636 Mail Service Center; Raleigh, North Carolina ~7699-1636
Location: 5.12 N. Salisbury St., Raleigh; North Carolina 27604
Phone: [phone] \ FAX: 919-807~96
Internet: www.ncwatemuality.org ·
An·Equ·a1 Opportunity\ Aflinnative Action Employer
Sincerely,
()t'l-1-fl A-~
forD~a~tts
Supervisor
:· One ... ·
North Carolina
:/yatilr4//g ·
Apr. 9. 2012- 4:54PM No. 2156—P, 2
f 04�
�
NO= CAII` UXA
DEPARTL MT OF ENVIRONMENT AND NATLT AL R OURCM (MCDENR)
NOTMCAIION OF MWr TO CONSTRUCT` 4 C1,091002' GEOTBI NAL
In Acoardam with tfie prtisviaxoB dW AC Tile BA: 02CO2M, pIAM
mnapiete this m:Aoaft end mmi to ed+itwo ante ba&, gaga (pl Prim ar 7)a8roioQ.
Waft aZyjm Con, finna*n: Doan tam prgmed system cb=hft pohibk [aa addWvdoj in
omtim vs *ing that oongdeWy Tsar tbo $tad fmm the en► i mment CLe..
das�locn77
Yens X Conews comp)eting this fWm.
lea Do Not aomple beds foam Complete o&er u[C appliaatica fm= for UWWEatg
eitber a SA? well (gM Imp wd Woodn pomble water ifo tho agu*r)ar a SQM w*l1 tc3mW-
ioop wee coo Wa&g &ddi� main as R 22. zd=ol, or odw andf=o or cmrmiaa inbfl itmr
A. PROPERTY 0VM{SYApPMCA (8)
Lin as& Prosy Qrwcer listed on props* deed (if owned by a bus3ceaa ar govornment agency, sty Ram of
eDtity and a representative wfauthority for sig mtute): D . iA Ali= S
StxtVACLOp Cadet Ca�,cryr. f
HomefGfftoe Tale Na: 9 C�
Em&U Addm;
(2) phyzical Address of V .�' a {9f ditrem thm above)!
City: Stain asp Cone' CoWsgr:
Hoanal fbo Taco No.: , C-_U_No.•
$. AVMOR=D AdENT OF OWMM. IF ANY (if The Permit Applicant does awa the, subject prcpwt rl
aitacha- low from tha proputy r►Huer aM "144g Agent to insO•a>nd operats'CT,CC wdi
Company Name: — -
Comact prntogiy(.AIL .4ddt.ss• _ ,
Addt�ss: .
C1rr; S iz. Zip Code: Cvumty:
Cou No..
Webs t=Mdress ofCompmyp i,Fsay� 1 /DENROWQ
-; ,. ... � fir
APR 4 9 Z0l2
►44Ufier PMW*,
RECEIVED� 0 09-' �.2 15 ; 31 FROh3- T0- NC D P&S

Ap r, 9. 2012 4:55PM -- No. 2156—P, 3
,
C- WELL DmLaIR to ORIWIO rt
CorrnppanrName:Y V t3 y��. _
Waif Driller Cottn='a Name: Jody bdalft i i ar evrammckm
NC Caaractrx C�a#i,aaNc�: 3+� A �Q3�;,a 3sas;.g,� _. _
CoataetP', David J.-moli.2j w—a - - AxL Add em-- AkMWkrQMM=
Addrew 1008 Hampt mMo Rd,
city: R
4MRZOVIRG 4pc4ae: 27024
O si"acaTeloga: 336•46"40 _ CenNe.: 33�3Tb-E736
D. MAIT MU P l;0pTRA==► It1H.� 1►I (if dzfferea! lhoa dariDos')
Coomd
aty: 6D Rs4= nN V =_Z# Lodi
Of &Z T& X04 5��• �I�f
E. STA3" Q'S OF APPLICANT
Pxivale: +/ FadataL•
5>ata: 3�miapm3:
Commsrclai:
WativeAmcdmLattds:
R INX8C nQX PRACRDIlI�__ B ( TkDy d bow As biffedeavyu(s) wiO be 0110
G6
W= C ISTRUCIMDATA '
(1)PsWasM date to be ong=W.' AN 1 9 �+u*xr bmiagc
q) 'i W dtabittlD be WW (WPM-, Mat), _ �,p-���p - l �i __� � •• _ _
(3) Wdl case, Is &o wcDCs) cwe3? (check either (a ) Yes _r (b) No below)
(1) Yes if yea, them proA& aft kr=aduu b4ow
Type: _ Melva d smd _—Mack steel Vlas& ahu (ePedfy)
❑wins dop k Pr=__.m *et (mforwc4 to land swtct),
cams aas& to ak" V*W d---. WW
(b) , Ifa
(d] �'� (amtnya► stlrra+mding Nell �& agar T?��3= �,���.iq*t t ��
(a) om at type: -Neat Coraer<t 'Bewopltei� 011" (spec:.M
(b) Grant Pub Pump Free =t oaw
(c) Ormt dbp& of tbblog (teftrem to bmd ice): from to. _ f�Cety
if wrx has oosqs ladloafs 9rcut aal*k fr9m _� to r f
*hc . ram
RECEIVED: 04- 9-' 12 IS: 31 FROM-
• • e! . I V iY
TO- NC DENR P&S . y v y P003/005

A r, 9, 2012 4; 55PM No. 2156—P. 4
1�L �D�F ATtt_i's`�RTS $Q�71pr �'r
Attscb a diagram show'lag tl e =&aft iayout or dosed moftea = of the iujection equipment aad exterior
pipiugltub* essoriate-d with the in ccdou op=r oa. The �Y.ecj'e pzeviie suiJpie�nentary
infs�txon
I. l;0CA170N OF q zLL(S)
Attach two wp6w of amps shu" f lha Wawtiog
(1) Iaoiuda a She Map (cm be dbswo) gwwiur. btdldinn ptapergr l t^ to&an wrier bodies; potmtlai
aonroea of gt?aaadwmw can=dnadon ad -the criathfivn of and dis'mioaes between ft proposed vreU(s) and
aW wdsftg tivWs) or waste Aspwal AdWas such as septic teals ar drain fields located Nvirbin 200 fed of
the geaftraW beat pmap well system. Label all YaaMes dears axed' s
(2) The Silt bbp m= skew the Seat group In relaSon to the s==&g tea by Uswg at lew two 9Vd
le*=& pans such as roads, m m ms, =for bi 1twayi omts.
X CMTIFG177ON 11
Note: Thtr Permit AppSaatto'a mlW bo sfpaA by lLak porava sppeorbg on the
xrecardod kgd properti dew -
"I heaeby sst*, tuzder pea&W of taw, *at I have pmenaliy cumalud end am NuOu wlth the bS=m w
su'bwood in Us doc ma mud %U audmaerts thereto and ths; booed on my Lmpiry of thaw is dMduab
immediately respo=i.[e for obWnhg raid frftmadon, I bcBtve rho# ihs ivf=m dcn is true, accu¢ata and comwate.
I ant amn tbat tbere are eagai�fitatat pie, i= tba po� of fps sued iwpisc am for svbmitfmg
£area axxformataoo. I ag= to comtmct operat46 msfaia, te*4 ad ifsppliaablo, abandoathe i$jeodon wall and
all rd&A2ppwWn&nros'h mcmila= wtGtbe aPzaoved spedd`icadcw gmdcoudlons of the permit"
She offnlied rty Qc+►svedAppuaaxrt .
• �J t11 �c� :r�It[-�
Ida a=
' � like os Type F�ANarae sad tads
- Si�ature of ►vnddppiia�
Prbst or Us PWW� wd We
r. M2
eipature of Awha Aged if wW
Priet oe�3�iilNtIDxe a��ie '
Pleeae xatam "0 copia of the pvmplered A,ppEcadoa package to:
Norfb Carofta DMM-DWQ
A4%itfar Pr+otcfion Sec dog UIC ProgMa '
*636Xa9 strAce C=!er RECENEDIDENRI0INQ
RWdgl4 I(rC 27699-1636 ,
TehThorie ( M 715.MS APR 9 9 ZU l
Aquifer ftlection Section
RECEIVED 04-09-'12 15:31 FROM- TO- NC DENS P&S P0041005
i- n 1. � . u - ..w .. r r - . r

A r. 9, 2012 4: 55PM No, 2156 P. 5
DaUA
RECENEDIDENMWQ
©col h APR 49 2012
Aquifer Protection Section
P14
r
ar �L f
700
16 Y
AQ
zz. 3
RECEIVED 04-05-'12 15:31 FROM- TO- NC DENR P&5 P005/005

Apr. 9, 2012 4; 54PM No, 2156 P. 1
FACS[MILE TRAKHMON FORM
DATE: 9 TIME: REF. NO. LOG NO.
TO c
COMPANY NAME yam. FAX NO, PLEAESykUELMR
Ari�E�aT101r r - �Li ImLy
FROM: 7�a&k_A_iWe-CL_.Cu . Z&
campoxy NAME - FAx NO. PEASE
0 HIM
NUMBER U PARES PLEUI ORIGINACOR'S
INCLUDING THIS $MEET - REPLY By S16NANR5 .
MESSAGE:
'FOR ALL Y41JR WATER NEEDS`
YADKIN WULL Co., INC,
!Soa HAS 4PTONVILLE �aao
NAM"ONVILLK. NC R70M
DAVIC J, BROWN, VICE PRES.
OFFICE-4620i 46&AA40
FAX [phone]
AEG LUC 468.465o
-0000 hews 0ma"ca , =a 6wis VOW
ECE Q_15 ; 31 FROM-
PWIiE NFOiFiNI CIS IIYN11®fIR�71R Y�100 NIpP R� F�AALR N. AJLL
TO— NC DENR P&S n P001I005